Reducing Hypertension Through Self-Measured Blood Pressure Monitoring Programs

September 29, 2025 | Ann Abraham

Hypertension remains a leading risk factor for cardiovascular disease and premature death in the United States — with disproportionate impact on historically marginalized populations, including African Americans, American Indians, Alaska Natives, and those living in under-resourced communities. Structural inequities in access to care, healthy food, safe environments, and trusted health systems have contributed to persistent disparities in blood pressure (BP) control. Addressing these requires not only clinical intervention but also intentional investment in quality improvement efforts that center patients’ needs, enhance care delivery, and integrate community and patient voices.

To pilot and/or refine existing innovative models that prevent, detect, and control hypertension, ASTHO — in partnership with the American College of Preventive Medicine — awarded mini-grants to a varied set of health systems and community organizations across several jurisdictions. Supported by dedicated funding and technical support, the following projects offer unique insights into evidence-based self-measured blood pressure (SMBP) monitoring programs that strengthen clinical-community linkages, identify patterns of success, and uncover systemic barriers to care.

Detroit: Henry Ford Health

Henry Ford Health in Detroit, MI, focused on young African American men, a population at risk of hypertension-related mortality. Building on their existing Express Blood Pressure Clinic — where patients are promised an appointment in less than 15 minutes to obtain a blood pressure reading — the team replaced Excel tools with a new REDCap data system to streamline workflows and track metrics like patient outreach, follow-up, and social needs. Nutrition consultants (primarily registered dietitian students) provided asynchronous engagement tools, including food logs, educational videos, and MyChart surveys. While engagement with nutritional services remained modest, satisfaction among participating patients is high. The team is testing strategies like MyChart messages from primary care providers and food-related incentives to increase outreach.

Tampa, FL: The IMAI Alliance

The IMAI Alliance in Tampa, FL, embedded hypertension screening and education into specialty care settings, particularly gynecology and orthopedics, where many women receive care outside of primary care. Patients received SMBP training and participated in a three-part virtual series on nutrition, DASH-based culinary medicine, and stress management.

Of 39 referrals, 16 patients enrolled. Despite barriers to enrollment such as travel and work schedules, participants reported a 60% reduction in perceived stress, and all reported making lifestyle changes. To improve accessibility, the team is exploring virtual cooking classes, shorter program formats, and flexible scheduling.

Baltimore: Johns Hopkins Medicine

Johns Hopkins Medicine in Baltimore, MD, launched an initiative to standardize SMBP workflows across seven primary care practices in the Maryland Primary Care Program. Guided by the MAP (Measure Accurately, Act Rapidly, Partner with Patients) Framework, the project introduced new EHR tools, Bluetooth-enabled devices, and support from interdisciplinary teams (i.e., pharmacists, nurses, and patient advocates). Challenges included the time-intensive setup of Bluetooth devices and limited automation for identifying non-reporting patients. The team is now exploring simpler alternatives and automated alerts to improve efficiency and sustainability.

Oklahoma City Indian Clinic

The Oklahoma City Indian Clinic tailored its approach to the urban American Indian/Alaska Native community it serves. A coordinated care plan identified patients with uncontrolled BP, offered home monitors, and referred them to a long-standing but underutilized Healthy Heart lifestyle class. In the pilot phase, 83% of participants reached BP control within one month, and patients reported feeling empowered to manage hypertension without immediate medication changes. The clinic plans to expand the program across all clinical teams, incorporate medical and pharmacy trainees, and offer virtual options to address transportation and scheduling barriers.

Columbia, SC: Prisma Health Midlands

Prisma Health Midlands in South Carolina revived its community-based group education for hypertension after COVID-related program suspensions. Guided by the MAP Framework, urban and rural practices referred patients, with preventive medicine residents conducting outreach. The 10-week group education sessions included weekly BP monitoring, lifestyle coaching, and support from trained health educators.

Despite challenges like short outreach timelines, transportation needs, and longer session timings that limited participation, participants reported increased motivation and positive impacts for their families. In response to challenges, the team plans to shorten the series, offer sessions biweekly, and engage primary care providers more directly in referrals.

Conclusion

Across all sites, several consistent themes emerged:

1. Patient-centered engagement strategies (i.e., tailored education, trusted communication channels, and flexible participation options) proved essential for increasing patient confidence and improving health behaviors.Projects that integrated SMBP monitoring, lifestyle medicine, and community-based education saw early gains in both engagement and clinical outcomes.
2. Team-based care was central to success.Nurses, pharmacists, community health workers, dietitians, and patient advocates played critical roles in addressing social needs and connecting patients to care.
3. Programs that were adaptable and responsive to patient life circumstances such as offering virtual classes, asynchronous education, or shortened sessions demonstrated better retention and greater patient satisfaction.
4. Robust data infrastructure allowed teams to track progress, identify barriers in real time, and refine strategies based on ongoing feedback.

This initiative demonstrates that intentional, short-term investments in team-based care and patient-centered design can lead to meaningful improvements in hypertension prevention and management. It also displays the effectiveness of the demonstration site model, which empowers locally based clinical teams to utilize funding and academic expertise for implementing programs best suited to make an impact among focused populations. While each site tailored its approach to its community, shared elements such as SMBP support, culturally relevant education, and flexible engagement strategies proved broadly effective. Challenges such as digital barriers, transportation, and retention remain, but teams are actively adapting their models in response. Together, these projects provide a roadmap for how scalable, evidence-based interventions can build momentum for long-term cardiovascular health.